HIV (Developing Countries)

Andrew George Excerpts

Wednesday 19th December 2012 Westminster Hall

[Pauline Latham (Mid Derbyshire) (Con)]

It is a particular pleasure to serve under your chairmanship today, Mr Bayley, because this debate is probably of more interest to you than many debates you have to chair, given your membership of the Select Committee on International Development.

I thank Mr Speaker for selecting this important debate on the rights, risks to and health of HIV patients in developing countries. I also thank the Under-Secretary of State for International Development, the hon. Member for Hornsey and Wood Green (Lynne Featherstone), for attending, and I hope she has fully recovered from her recent illness. Before I start—as this would not be appropriate at the end—I wish everyone a happy Christmas and a peaceful new year.

The Global Commission on HIV and the Law, chaired by the former President of Brazil, recently published a report the findings of which are the reason why I wanted to secure this debate. If there is just one point that I want everyone to take away with them today, it is this quote from the commission’s chairman:

“The end of the global AIDS epidemic is within our reach.”

We have the unprecedented opportunity of a generation to have a world where no one dies of AIDS-related illnesses or newly acquires HIV. It is now a realistic ambition to imagine an HIV-free generation.

Some three decades ago, the HIV epidemic was first discovered. Since then, 30 million have died of AIDS, and 34 million more have been infected with HIV. The epidemic became one of the greatest public health challenges of our time. However, as the report makes clear, the crisis is also one of law, human rights and social justice. We are now fortunate enough to live in an age where we have all the research and tools to slow radically the rate of new HIV infections and stop HIV-related deaths, but the AIDS epidemic is not over. This time, it is not nature that is getting in our way of achieving success; this time, we are the problem. Bad laws, political obstacles and straightforward discrimination are preventing us from combating one of the greatest challenges ever to face humankind. We, as members of the human race, are standing in the way of ourselves.

Before I go on, it is important to praise United Kingdom Governments over the past 30 years—Conservative, Labour and now the coalition—for their work and for being global leaders in the response to HIV for much of the past 30 years. Tribute should be paid to Lord Fowler, who, as Health Secretary, opened up the discussion about HIV/AIDS at a time when many hesitated to speak its name, and initiated the striking “tombstone” adverts to alert the public to the nature of the new and dangerous disease. That is something the British people should feel proud of and that should continue, as I am sure we all agree. Perhaps we are ready again for a public health awareness campaign.

As many Members present will be aware, I undertake a lot of work on international development, and an issue that almost always arises in developing countries is gender inequality. Women and girls account for half the people living with HIV in the world. In Africa, the rate is even higher. Poverty repeatedly features, as almost all women with HIV—98%—live in developing countries. Why are women so vulnerable to HIV there? Their vulnerability can partly be put down to biological reasons, but the real reason is the gender inequality and discrimination enshrined in the customs and law and sexual and domestic violence that rob women of power. The United Nations special rapporteur on violence against women found that the majority of sexually active girls in developing countries aged 15 to 19 are married, often to much older men, and such married adolescents tend to have higher rates of HIV infection than their peers.

Sexual violence is the accomplice of HIV, depriving women of their ability to control their lives and thereby protect their health. In 2005, a World Health Organisation study found that in a broad range of settings, men who were violent towards their female partners were also more likely to have multiple partners, with both violence and infidelity being expressions of male privilege. I have previously spoken in this Chamber about rape being used as a tool of war. Increasingly, it is a weapon to break the spirits of women and girls, because, as the global commission’s report rightly points out, it destroys what holds people together—a community.

Disclosure of positive HIV status puts women at risk and in fear of more violence. I recently visited Pakistan, and when I returned home, I read about a Pakistani woman who had been gang-raped. She later discovered that she was both pregnant and HIV-positive. Her husband then abandoned her and her children. The commission’s report cites an example that demonstrates that education and class do not necessarily insulate women from such outcomes. It describes how a Tanzanian woman who led a middle-class life and was happily married to a professional man was affected. When she told him of her positive status, he was furious and started blaming her for their sons’ illnesses. He exposed her to stigma and torture, expelling her from the matrimonial home that she had paid for with her own money. The divorce courts did nothing to uphold her rights or to help her children.

We know that many women in the Democratic Republic of the Congo suffer rape, often in front of their husbands and children, who are then murdered in front of them. As a result, the women are frequently victims of HIV/AIDS, and they have few places to go for help. Antiretroviral drugs are much more difficult to obtain, administer and take consistently in such a chaotic place.

I welcome the commitment of the Department for International Development to putting women and girls at the centre of its work in the developing world. However, the Government have to urge other Governments, particularly at the G8 next year, to adopt the same strategic priority in their international development policies.

Another issue is Governments such as Uganda’s wishing to introduce laws making gay sex illegal and punishable by the death penalty. Many Governments in Africa are intolerant of gay sex. If challenged by UK Members of Parliament such as the late David Cairns, their Ministers try to tell us that they are just continuing with the laws we left with them following independence. That is some 50 years ago, so it is absolutely no excuse. We have moved on in the past 50 years and so should they.

There was a debate in Westminster Hall about the brutal murder of Ugandan gay rights activist David Kato. Since then, I have met a number of young gay men from African countries who are frightened for their lives. Such repressive laws must be outlawed, and it is up to our Ministers in the Foreign Office and DFID to stand up to Governments in countries where such laws are a problem.

Not only are the laws frightening gay men; they are a recipe for disaster in the fight against HIV/AIDS. Men will go underground; they will not see their doctor if they suspect they have HIV, because they are terrified they will be labelled as gay. They will not even want to collect drugs from a pharmacy for exactly the same reason.

A Bill has been tabled in Uganda—it is supposed to go through by the end of the year, so it is not long—proposing to expand the scope of criminalised activities and provide harsher punishments on conviction, including life imprisonment and, unless the clause in question is definitively removed, the death penalty for some offences. The Bill will force anyone who is aware of an offence under the Bill or an offender to report the offender within 24 hours, or be liable to a fine or three years’ imprisonment. There are indications that the clause might be dropped or amended, but if it remains the draconian provisions will punish any parent who does not denounce their lesbian daughter or gay son to the authorities. They will face fines of 2,650 dollars or three years in prison. Any teacher who does not report a lesbian or gay pupil to the authorities within 24 hours will face the same penalties. That must not happen, and I call upon the Minister to try to do something to stop it.

As the global commission’s report states, children and young people have the most to lose from HIV. It also states that such children are far more likely to become poor or homeless, drop out of school, face discrimination and violence, see their opportunities dwindle, or grow ill and die long before their time. The research quoted in the report states that globally, there are 3.4 million children living with HIV, roughly 16.6 million of whom have lost one or both parents to AIDS, and millions more have been affected. Fewer babies are now born with HIV, thanks to an increase in programmes to prevent vertical transmission. However, less than one quarter of children who qualified for the standard antiretroviral therapy actually received it in 2010. Despite that treatment, 2,500 young people still acquire HIV every day.

Young people in developing countries are also affected if their parents become ill or die. That point is in many ways linked to the gender rights issues I raised earlier, as older children, especially girls, are often forced to leave school to care for the family if a parent dies. That becomes a vicious circle for girls, trapping them for life, meaning they cannot have a long enough education to become economically independent, and elevating their risk of being infected by HIV. We must ensure that when parents die, developing states are well enough equipped to provide children with human rights and to make sure that their legal interests are protected, and that they are being cared for by suitable people.

Then, there is the issue of discrimination against families living with HIV. Adults living with HIV may be denied rights to see their children. Agencies prohibit HIV-positive children from living with their parents in state-sponsored housing, and school and child care administrators shut the door to HIV-positive pupils, believing that they will infect others. For example, in Paraguay,

“People who suffer from chronic contagious disease”

are forbidden to marry or adopt. Challenging those legal obstacles is a particularly important role for non-governmental organisations. Gidnist, the Ukrainian legal aid NGO, challenged the Ukrainian court to protect the rights of an HIV-positive child who was denied access to the paternal home. Thanks to that legal action, the child’s access to his paternal home was restored.

Studies cited in the global commission’s report state that age-appropriate, comprehensive sex education, including information on HIV prevention, serves the health of young people. Those studies show that such programmes reduced sexual risk-taking. If we are serious about working towards an HIV-free generation, it is therefore vital that age-appropriate sex education be available in schools worldwide.

As I briefly mentioned, among the things that stand in our way are the laws and political thought in some developing countries. The global commission’s report makes it clear that HIV is not just a health issue. The report makes for sober reading, informed as it is by those at the sharp end of the making and breaking of HIV-related laws in more than 140 countries. The global commission heard from people living with HIV who are deprived of the medicines they need because of intellectual property laws that put the prices out of reach. Men who have sex with men, and female sex workers, told the commission of their harrowing experiences of arbitrary arrest and abuse by police. People who inject drugs spoke of their time in detention, when they were denied clean needles or substitution therapy to help them reduce the harms associated with their habit. The commission heard about the experiences of migrant workers expelled from countries with laws that ban the entry of, or deport, foreigners with HIV, and the experiences of HIV-positive citizens denied health care, schooling, employment or housing because of stigma and discrimination.

Many companies help their own work forces by providing antiretroviral drugs, antimalarial drugs and other drugs that families need, in order to keep a healthy work force. In Uganda, we saw people from Nile Breweries give such drugs not just to their own workers but to the farmers who provide the agriculture for them—I forget which plant they make beer from. However, they also provide condoms for sex workers. There are people out there trying to help, and they are not just from NGOs and Governments, but from companies. That is encouraging to hear.

[Andrew George (St Ives) (LD)]

I am grateful to my hon. Friend for making a very strong case, particularly with regard to the attitudes that must be overcome in order to address this issue. Does she agree that one answer clearly must be further integration of HIV systems—not a separation of HIV systems—within an integrated health systems approach, particularly in circumstances in which TB is the major killer of people with HIV? In view of those circumstances, does she agree that what we can do in this country is to ensure that the UK continues to take a leading role in addressing the replenishment issue with regard to the Global Fund to Fight AIDS, Tuberculosis and Malaria?

[Pauline Latham]

I thank my hon. Friend for those comments. I will come on to those points in a moment, but they are very important because we do need an integrated approach. It cannot be a stand-alone approach; it has to work together with other things.

The global commission’s findings clearly demonstrate that the myriad laws, across multiple legal systems, have one thing in common: by punishing those who have HIV or the practices that may leave them vulnerable to infection, they serve simply to drive people further away from disclosure, testing and treatment—fostering, not fighting, the global epidemic.

To quote Dr Shereen El Feki, the representative from Egypt on the global commission,

“It is time to say, ‘No more.’ Just as we need new science to help fight the viral epidemic, we need new thinking to combat an epidemic of bad laws that is undermining the precious gains made in HIV awareness, prevention and treatment over the past thirty years.”

I absolutely support her position. She argues, and I agree, that deliberate and malicious transmission of HIV is best prosecuted through existing laws on assault, homicide or bodily harm, rather than the special HIV criminal statutes that have sprung up in recent years and that sweep up those—pregnant women among them—to whom they should never apply.

In relation to pharmaceuticals, existing intellectual property laws require a complete overhaul to ensure that the interests of public health are balanced against incentives for innovation, and that the best new HIV medicines are available to all. Laws that criminalise sex work, drug use, same-sex relations or transgender identity do little to change behaviour aside from discouraging the people most at risk of infection from taking measures to protect themselves and their communities from HIV. Laws against gender-based violence and towards the economic empowerment of women are badly needed, and need to be enforced, to reduce women’s vulnerability to HIV. To work towards making an HIV-free generation a human reality, the world needs to take a joined-up, 21st-century approach to, as I said, one of the greatest public health challenges of our time.

Let me now discuss what my hon. Friend the Member for St Ives (Andrew George) mentioned in his intervention. Since the Global Fund to Fight AIDS, Tuberculosis and Malaria was created in 2002, it has saved an estimated 7 million lives, disbursed antiretroviral drugs to more than 3 million people, treated 8.6 million cases of TB and distributed 230 million insecticide-treated bed nets.

[Pauline Latham]

I thank the hon. Gentleman for that intervention. We need drugs to be regularly available at an affordable price, but many countries where the problem is rife are chaotic and often in conflict, so the drugs would not necessarily get to where they are needed.

We have a role to play with DFID, because we provide a lot of health strengthening in different countries, but we must ensure that the health strengthening in the Governments is true. Often a Government will take money out of the health system, because we have put it in. We must ensure that the systems we put money into to fight this huge epidemic are absolutely transparent. It is also important that drugs are age-related; a drug for a young child will not be the same as a drug for somebody in their 50s. The hon. Gentleman makes an important point.

The global fund is the largest international financier of the fight against the three diseases. It channels two-thirds of the international financing provided to fight TB and malaria and half of all antiretroviral drugs to people living with HIV and AIDS. It also funds the strengthening of health systems. Inadequate health systems are one of the main obstacles to scaling up interventions to secure better health outcomes for HIV, TB and malaria. In contrast to other multilateral institutions, the global fund has been ranked by DFID as performing very highly on transparency and accountability. However, 2011 was a difficult year for the global fund, as the cancellation of the round 11 funding caused great concern among non-governmental organisations delivering services through the fund in developing countries.

In 2012, the Select Committee on International Development, of which I have been a member since the 2010 general election, held a short inquiry into the global fund. It concluded that the UK Government should release the additional funding promised to the fund without delay. In the Government’s response to the inquiry, DFID unfortunately states that they will wait until after the second multilateral aid review, which is due to be published in spring 2013.

The global fund has gone through a huge transformational process, developing a new strategy and recently appointing a new executive director, Mark Dybul. It now has a new funding model. Due to financial constraints, however, the fund has withdrawn its programme from some middle-income countries, such as Ukraine, where the figures on the HIV epidemic are rising. Will the Minister look urgently at that?

On drugs, it is worth noting that approximately 80% of the 8 million people currently taking ARVs are prescribed generic versions. Competition in generic drugs has enabled the cost to be reduced at least tenfold to around $100 a year for first-line treatment. That was only possible due to India’s pre-2005 patent laws and protracted discussions with the pharmaceutical industry in the late 1990s and early 2000s. Since India’s patent laws have become compliant with the agreement on trade-related aspects of intellectual property rights—TRIPS—it is not possible for Indian companies to make generic versions of newer medicines within the 20-year patent period. We are, therefore, reliant on the good will of pharmaceutical companies to reduce prices for poorer countries.

During 2012, it is estimated that about half a million people will need second and third-line treatment, which is patented and at least three times the price of first-line treatment. Third-line treatment is as much as 20 times the price. One initiative to deal with the cost of drugs is the medicines patent pool, which would enable free generic competition on newer patented medicines. Unfortunately, only one company—Gilead Sciences Inc—has signed up and more companies need to join for the system to be viable. Will the Minister comment on what she plans to do to help that happen?

As we move towards 2015, a lot of work is being undertaken to put together a post-millennium development goals framework. One risk we face as the MDGs come to an end is that the global community will turn its back on the gains made in the past decade. It is important to consider the linkages between HIV/AIDS and other diseases. A post-MDG framework must continue to work towards the unmet MDGs. There is an urgent need for continued action on HIV: each day more than 7,000 people are newly infected with HIV; and 7 million people are still in need of HIV treatment—a number set to increase dramatically as all 34 million people living with HIV will ultimately require it.

TB is the leading cause of death among people infected with HIV/AIDS in developing countries, and 1.1 million people were living with HIV-acquired TB in 2010. Because HIV infections attack and weaken the immune system, an HIV-positive person with latent TB is 20 to 40 times more likely to develop active TB than someone who is not infected with HIV. Promoting and implementing the linkages between HIV and other relevant areas—including gender, sexual and reproductive health, maternal and child health, TB, education, and hunger and nutrition—brings wider benefits for development. A post-2015 framework must therefore ensure that goals and targets support synergies between areas. In particular, it must ensure that addressing HIV is part and parcel of a coherent and holistic approach to strengthening overall health, social protection and legal systems. Will the Minister tell us what progress she hopes will be made at the G8 next year?

[Andrew George]

My hon. Friend has made an extremely important point, which echoes my intervention on the integration of services. Does she agree that it is a serious false economy if developing countries do not ensure that the drugs are delivered on the ground? The cost of treating drug-resistant strains of TB—such strains are an increasing problem—is much greater than the cost of investment on the front line to treat such cases in the first place.

[Pauline Latham]

My hon. Friend is right; if we cannot get the drugs out to the people, they will not do well, so systems need to be put in place. It is ironic that many African countries have appalling transport systems and yet organisations such as Nile Breweries, which makes beer, can get drugs to people, no matter how difficult it may be, because beer gets everywhere, whereas Governments do not always think it important to ensure that pharmacies and health clinics do not have stockouts. All African countries need to ensure that there is blanket coverage of such drugs and that there is never a shortage, because, as my hon. Friend mentioned, to do otherwise is a false economy. They need to work hard to move forward on prevention, because so many people are living with, and still dying from, HIV/AIDS.

I started by saying that the key point I wanted everyone to take away today is that the end of the global AIDS epidemic is within our reach. Working towards an HIV-free generation is now a possibility, but it will become a reality only if we have the will to make it a reality. I shall repeat what I said earlier: nature is not standing in our way; we, as members of the human race, are standing in our way. We must urge the Governments of the world to take a joined-up approach to combating HIV/AIDS.

I also started by praising the work of UK Governments over the past three decades. The UK has provided excellent political and financial support. It is clearly an example of best practice and has set the standard for others to follow. The UK Government will review their HIV programmes in 2013. I agree with the Stop AIDS Campaign, which urges that the 2013 review becomes a blueprint or strategy for the future of the UK’s global HIV work. It is a chance to demonstrate the UK’s continued leadership in the field.

The strategy would map the UK’s contribution to delivering the combination of game-changing interventions necessary to ensure that we reach the tipping point and have a generation in which no one dies of an AIDS-related illness or newly acquires HIV and in which the rights of all those living with or affected by HIV are upheld. I also agree with the Stop AIDS Campaign that the blueprint should include three key themes: first, commit to maintaining the UK’s investment in HIV/AIDS; secondly, commit to putting all people living with and affected by HIV at the centre of the response, regardless of where they live; and thirdly, commit to leading the way in the UK and globally.

It was a privilege to secure this debate and speak on this important issue. I thank you for your chairmanship, Mr Bayley. I thank everyone who has attended and the various organisations that provided me with briefings ahead of the debate. I look forward to hearing other Members’ contributions and particularly the Minister’s response.